# Hospital Discharge Report - HL7 Europe Hospital Discharge Report v1.0.0-alpha

* [**Table of Contents**](toc.md)
* **Hospital Discharge Report**

## Hospital Discharge Report

### Hospital Discharge Report Overview

#### Hospital Discharge Report

The Hospital Discharge Report (HDR) has main components:

* the header and
* the body.

 The **header** contains essential administrative and identification data about the patient, healthcare providers, and other key participants in the patient's care.

The **body** consists of the core clinical details regarding the patient's stay, treatment, and discharge plan.


#### Header

 The Hospital Discharge Report Header component provides a documentation for the: 
*  **Identification of the patient/subject:** This includes critical identification information like the patient's **given name**, **family name**, **date of birth**, and **national healthcare patient ID**. It also covers **nationality**, **gender**, and the patient’s **country of affiliation**. 
*  **Patient/subject related contact information:** This involves the patient’s **address** and **telecommunication contact details** (e.g., phone numbers and email addresses). It may also include details of a **preferred healthcare professional** (name, identifier, role, organization).
*  **Health insurance and payment information:** Key data related to health insurance, including the **insurance code**, **name of the health insurance provider**, and the **patient's health insurance number**. 
*  **Information recipient:** Refers to the intended recipient of the hospital discharge report. This includes **recipient's name**, **organization**, **address**, and **telecom details**. 
*  **Author:** Documents the **author of the report**, including their identifier (e.g., license number), name, and organizational information. The author is responsible for signing off on the content of the report.
*  **Attester:** The healthcare professional who verifies the content of the report. This includes the **attester’s identifier**, **name**, **organization**, and the **date and time of attestation**. 
*  **Legal authenticator:** The person taking legal responsibility for the report. Includes the **identifier**, **name**, **organization**, and **date of authentication**. 
*  **Document metadata:** Contains the document's unique **identifier**, **type**, and metadata such as the **date and time** of creation or modification, ensuring proper tracking of the report.
 


#### Body

 The Hospital Discharge Report Body component includes: 
*  **Presented form:** the Hospital Discharge Report in its narrative form; that is in a printable representation.
*  **Advance directives:** Legal documents like living wills or DNR orders guiding treatment decisions.
*  **Alerts:** Important medical alerts like allergies or other critical patient conditions.
*  **Encounter:** Details of the hospital encounter, including admission date, reason, and type (inpatient/outpatient).
*  **Admission evaluation:** Key findings and diagnostic results from the admission process.
*  **Hx general Reported:** A comprehensive record of the patient’s medical history prior to the hospital stay.
*  **Course of hospitalisation:** Progress of the patient during the hospital stay, including treatments and interventions.
*  **Discharge details:** Information about the discharge date, destination, and post-discharge care instructions.
*  **Care plan and other recommendations after discharge:** Detailed follow-up care plan, including medications and therapy recommendations.
 


